UST General Requirements Inspection Checklist

Transcription

1 UST General Requirements Inspection Checklist Inspection Date: Inspector s Name: Facility ID#: I. Ownership of s II. Location of s Owner's Name (Corporation, Individual, Public Agency, or other entity): Facility Name: Street Address: Street Address: City: Phone Number: State: NC Zip Code: County: City (nearest): Zip Code: Number of UST systems on site (including non-regulated): Contact Person for UST Location: Phone Number: Operator Name: Facility Phone Number: Date ownership of the UST systems began: Date individual became operator of the UST system: III. Certified Operator (Class A/B) Certified Operator Name (print legibly): Operators Title: Company Name: Certified Operator (Class A/B) has passed training? Yes No Phone Number: Class C operator log (UST-26) onsite and completed with names of trained employees? Yes No Onsite Class C operator is listed in training log? Yes No IV. UST Information 1. Current tank status (Currently Operating, Temporarily Closed, Permanently Closed, Unknown) 2. If not currently operating, date last operated 3. If not currently operating, list inches of product in tank 4. and year UST system installed 5. Material of tank construction (note SW or DW) DW required if installed after 11/1/07 6. UST piping installed on or after 11/1/2007? (Y/N) 7. Material of piping construction (note SW or DW) DW required if installed after 11/1/07 8. Capacity of tank (gallons) 9. Substance stored (Premium, Mid-grade, Regular, E- Blend, Diesel, Biodiesel, Biodiesel Blend, Kerosene, Waste Oil, New Oil, Racing Gas, etc.) 10. If E-blend > 10% or Biodiesel Blend > 20%, was UST-20 completed and approved? (Y/N) V. Leak Detection (Indicate which method is being used according to the owner / operator) 1. s: (Inspector description or use codes) 2. Piping: (Inspector description or use codes) 3. Pressurized, Suction or European Piping: (P/S/E) Use the following codes for leak detection: [s Only]: IC/TTT = Inventory Control & Tightness Testing, ATG = Automatic Gauging, MTG = Manual Gauging [Piping Only]: LTT =Line Tightness Testing, E =Electronic Line Leak Detector [s and/or Piping]: SIR = Statistical Inventory Reconciliation, G =Groundwater Monitoring, V =Vapor Monitoring, I =Interstitial Monitoring, N =None, O = Other Page 1 9/30/09

2 Corrosion Protection I. Corrosion Protection Information A. Corrosion Protection for s: Dielectric Coating Installed (If tank installed after 12/22/1988) B. Corrosion Protection for Piping: Dielectric Coating Installed (If piping installed after 12/22/1988) Use the following codes for corrosion protection: IC =Impressed Current, CLAD =Steel-Fiberglass Reinforced Plastic Composite, FRP =Fiberglass Reinforced Plastic, sti-p3, FLEX =Flexible Piping, IL =Interior Liner, SA =Sacrificial Anodes, N =None, O =Other (specify) II. Cathodic Protection Detail A. Integrity Assessment - Internal inspection in accordance with API-1631 or NLPA 631? (Only complete for the following situations) 1. When required by the current version of the Procedures for UST Systems with Inoperative or Failed Corrosion Protection Systems, OR Y/N P/F Date List applicable tank ID s: 2. When, after 3/1/06, an internally lined tank (lined more than 10 years ago) is upgraded with a field installed corrosion protection system and the tank owner does not want to perform the 10 year or subsequent every 5 year lining inspections. B. Interior Lining Y/N P/F Date 1. The date the tanks were initially lined. 2. Has an internal inspection been conducted in accordance with a national code (API-1631 or NLPA-631) within 10 years of liner installation and every 5 years after that? C. Cathodic Protection Design (Only complete this section if a field installed CP system is installed after 3/1/06 for the first inspection after the installation) Did a corrosion expert design the CP system? Corrosion Expert Name: Certificate Number: Certifying Organization: CP Start Date: Y/N D. Cathodic Protection Testing Y/N P/F 1. Has a CP test been conducted within past three years? CP Tester Name: Certificate Number: Certifying Organization: Date of Last CP Test: CP Testing Company: City: State: 2. Was a UST-7A/B form submitted to the UST Section? (Y/N and Date) 3. Are the last three "60 day" inspection records available for the impressed current system? (Y/N) 4. What was the voltage and current set at after the last test of the impressed current system? V A 5. What is the voltage and current currently reading for the impressed current system? V A Page 2 9/30/09

3 Leak Detection for Piping I. Pressurized Piping 1. Line Leak Detectors (3.0 gph) (MLLD, ELLD, None) 2. Manufacturer of MLLD/ELLD System 3. Name/Model of MLLD/ELLD System 4. Is MLLD/ELLD System Third-Party Certified? (Y/N) 5a. Most recent LLD test (Date-required annually) 5b. LLD test result (Pass, Fail, Inconclusive) 6a. Most recent LTT (Date) (Required annually or every 3 years if installed after 11/1/07 and monitored by sump sensor) 6b. LTT result (Pass, Fail, Inconclusive) 7. ly monitoring method (use LD codes below) Leak detection codes: SIR =Statistical Inventory Reconciliation, G =Groundwater Monitoring, V =Vapor Monitoring, I =Interstitial Monitoring, E =ELLD II. Standard (American) Suction Piping 1a. Most recent LTT (Date - required every 3 years) 1b. LTT result (Pass, Fail, Inconclusive) 2. ly monitoring method (Use LD codes below) Leak detection codes: SIR =Statistical Inventory Reconciliation, G =Groundwater Monitoring, V =Vapor Monitoring, I =Interstitial Monitoring III. Safe (European) Suction Piping 1. Operates at less than atmospheric pressure (Y/N) 2. Only one check valve, directly under pump (Y/N) 3. Slope of piping allows product to drain back into tank when suction is released (Y/N) 4. Above information (1,2,3) is verifiable (Y/N) IV. Supporting Information A. Line Tightness Test Method Manufacturer and Name/Model of LTT: B. Line Leak Detector (Mechanical / Electronic) Equipment and Line Tightness Testing MLLD/ELLD/LTT Tester Name: Is LTT Third-Party Certified? (Y/N) Yes No MLLD/ELLD/LTT Testing Company: City: State: Phone Number: C. ELLD ly Monitoring Results (Use Page 7, 8, 9, 10, 13 or 14 for any other method) (P =Pass, F =Fail, INC =Inconclusive, N = None) JAN JUL FEB MAR APR MAY JUN AUG SEP OCT NOV DEC Is leak detection being conducted in accordance with third party performance claim? Yes No Page 3 9/30/09

4 UST Siting and Spill / Overfill Prevention I. Water Supply / Protected Waters UST Siting Issues YES NO 1. Is municipal water available? 2. Do any businesses or homes within 500 feet of the UST system use a human consumption well? 1 3. Are there any protected surface waters* within 500 feet of the UST system? 1 *classified as High Quality Water (HQW), Outstanding Resource Water (ORW), Water Supply I (WS-I), Water Supply II (WS-II) or Shell Fishing (SA) 1 If either questions 2 or 3 are answered with a YES, complete Page 16 II. Site Diagram / Comments If needed, indicate the location of the following: tanks dispensers permanent structures (distances to) roads water supply wells monitoring wells surface waters other things of interest III. Spill and Overfill Prevention Equipment 1. Spill prevention equipment present? (Y, N) 2. Spill bucket is double-walled? (If installed after 11/1/07) 3. Spill bucket is isolated or made of non-corroding materials? (If installed after 11/1/07) 4. Overfill prevention equipment: (Ball Float, Flapper Valve, High-Level Alarm, None) 5. Overfill prevention equipment verified? (Y, N) 6. Annual Overfill check date (if installed after 11/1/07) 7. Annual Overfill check results (if installed after 11/1/07) (P, F, N/A) 8. Is a drop tube present? (Y, N) 9. Stage I vapor recovery present? (Co-axial, Dual Point, None) IV. Permit Information 1. Permit Expiration Date: 2. Transporter / Fuel Deliverer: (Mandatory field) 3. listed on operating permit? (Y, N) 4. Any deliveries to unpermitted tank? (Y, N) If yes, complete Page 17, Deliveries to Unpermitted s. Page 4 9/30/09

5 Sumps / Under Dispenser Containment I. Top Sumps 1. Flex connector, Piping extensions, and/or other metal fittings present: (F, BV, E, M, N, Unk)* 2. Flex connector is isolated from the ground: 3. Submersible pump (STP) is isolated from ground: 4. Piping extensions and/or other metal fittings are isolated from ground: 5. Flex connectors, STP, piping extensions, or other metal fittings are cathodically protected by: (IC, SA, N, N/A)** 6. Dielectric Coating Installed (If metal installed after 12/22/88) 7. Are tank top containment sumps present? (Y, N) 8. Any releases evident in tank top sumps? (Y, N) 9. Are single-wall piping components located in a containment sump? (If installed after 11/1/07) IV. UDC Disp # Disp # Disp # Disp # Disp # Disp # 1. Flex connector, Piping extensions, and/or other metal fittings are present: (F, BV, E, M, N, Unk)* 2. Flex connector is isolated from the ground: 3. Piping extensions and/or other metal fittings are isolated from ground: 4. CP for flex connectors, piping extensions, or other metal fittings: (IC, SA, N, N/A)** 5. Dielectric Coating Installed (If metal installed after 12/22/88) 6. Are dispenser containment sumps present? (Y/N) 7. Any releases evident under the dispensers? (Y, N) 8. Are single-wall piping components located in a containment sump? (If installed after 11/1/07) 9. Dispensers have current calibration stickers (Y/N) 1. Flex connector, Piping extensions, and/or other metal fittings are present: (F, BV, E, M, N, Unk)* 2. Flex connector is isolated from the ground: 3. Piping extensions and/or other metal fittings are isolated from ground: 4. CP for flex connectors, piping extensions, or other metal fittings: (IC, SA, N, N/A)** 5. Dielectric Coating Installed (If metal installed after 12/22/88) 6. Are dispenser containment sumps present? (Y/N) 7. Any releases evident under the dispensers? (Y, N) 8. Are single-wall piping components located in a containment sump? (If installed after 11/1/07) 9. Dispensers have current calibration stickers (Y/N) * (F=Flex Connector, BV= Ball Valve, E= Elbow, M=Other Metal, N=None, Unk=Unkown) ** (IC= Impressed Current, SA = Sacrificial Anode, N= None, N/A = Not applicable) Disp # Disp # Disp # Disp # Disp # Disp # Page 5 9/30/09

6 Leak Detection Automatic Gauge I. Automatic Gauge Information Manufacturer and Name/Model of ATG Console: Is ATG Console Third-Party Certified? Yes No ATG Probe: Capacitance Magnetostrictive II. ly Automatic Gauge Monitoring YES NO N/A 1. Is the ATG console present and operational? 2. Were all valid fail tests reported to the division within 24 hours? 3. Were all valid fail tests investigated within 7 days? III. Automatic Gauge Test Results If Enhanced Leak Detection required per 2N.0304 then: Weekly Test required at 0.2 gal/hr OR a ly Test required at 0.1 gal/hr ATG Test Results: P = PASS F = FAIL I = Inconclusive N = None January February March April May June July August September October November December Is leak detection being conducted in accordance with third party performance claim? Yes No Page 6 9/30/09

7 Leak Detection Interstitial Monitoring (prior to 11/1/07) I. Interstitial Monitoring on s 1. Construction type (Double-walled, External liner) 2. Method of interstitial monitoring (Electronic, Mechanical, Visual) 3. Monitoring frequency (Continuous or Periodic) II. Interstitial Monitoring on Piping Pipe Pipe Pipe Pipe Pipe Pipe 1. Construction type (Double-walled, External liner) 2. Method of interstitial monitoring (Electronic, Mechanical, Visual) 3. Monitoring frequency (Continuous or Periodic) III. Interstitial Monitoring - Electronic Manufacturer and Name/Model of Interstitial Monitoring Console: Manufacturer and Name/Model of Interstitial Monitoring Probe - : Is Interstitial Monitoring Probe Third- Party Certified? Yes No Manufacturer and Name/Model of Interstitial Monitoring Probe - Piping: Is Interstitial Monitoring Probe Third- Party Certified Piping? Yes No IV. External Liner YES NO 1. Is the secondary barrier constructed from artificially constructed material, with permeability to substance 10-6 cm/sec? 2. Does the secondary barrier interfere with operation of cathodic protection system? 3 If monitoring wells are part of the leak detection system, are the monitoring wells clearly marked as monitoring wells and locked to avoid unauthorized access and tampering? 4. Is the groundwater table always below the bottom of the secondary barrier? 5. If the water table may reach the bottom of the secondary barrier, are the monitoring designs appropriate under such conditions? V. Interstitial Monitoring Results (P =Pass, F =Fail, INC =Inconclusive, N= None) January Pipe Pipe Pipe Pipe Pipe Pipe February March April May June July August September October November December Is leak detection being conducted in accordance with third party performance claim? Yes No Page 7 9/30/09

8 Leak Detection Interstitial Monitoring (after 11/1/07) Manufacturer and Name/Model of Interstitial Monitoring Console: I. s 1. Manufacturer of Sensor UST-6B 2. Name/Model of Sensor UST-6B 3. Monitoring type (Pressure, Vacuum, or Hydrostatic) UST-6B 4. Sensor Third-Party Certified (Y/N) 5. Sensor Operability Check Date (required annually) UST Sensor Operability Check Results (P/F) UST-22 II. Spill Buckets 1. Manufacturer of Sensor UST-6B 2. Name/Model of Sensor UST-6B 3. Monitoring type UST-6B (Float sensor, Pressure, Vacuum, or Hydrostatic) 4. Sensor Third-Party Certified (Y/N) 5. Sensor Operability Check Date (required annually) UST Sensor Operability Check Results (P/F) UST Tightness Test Date (if monitored by Float sensor) UST-6D/23A (required every 3 years) 8. Primary bucket Tightness Test Result (P/F) UST-6D/23A 9. Secondary bucket Tightness Test Results (P/F) UST-6D/23A III. Sumps 1. Manufacturer of Sensor UST-6B 2. Name/Model of Sensor UST-6B 3. Monitoring type (Sump Sensor, UST-6B Pressure, Vacuum, or Hydrostatic) 4. Sensor Third-Party Certified (Y/N) 5. Sensor Op Check Date (annually) UST Sensor Op Check Result (P/F) UST Sump Visual Inspection Date (required annually) UST Sump Visual Inspection Results (P/F) UST Sump Tightness Test Date (if monitored by Sump sensor) (required every 3 years) UST-6F/23B 10. Sump Tightness Test Result (P/F) UST-6F/23B IV. Piping Pipe Pipe Pipe Pipe Pipe Pipe 1. Manufacturer of Sensor UST-6B 2. Name/Model of Sensor UST-6B 3. Monitoring type UST-6B (Sump sensor, Pressure, Vacuum, or Hydrostatic) 4. Sensor Third-Party Certified (Y/N) 5. Sensor Operability Check Date (required annually) UST Sensor Operability Check Results (P/F) UST Secondary Tightness Test Date UST-6G/23C (if monitored by Sump sensor) (required every 3 years) 8. Secondary Tightness Test Result (P/F) UST-6G/23C 9. Secondary Tightness Test done in accordance UST-6G/23C with manufacturers instructions? (Y/N) Page 8 9/30/09

9 Leak Detection Interstitial Monitoring (after 11/1/07) V. UDC Dsp Dsp Dsp Dsp Dsp Dsp 1. Manufacturer of Sensor UST-6B 2. Name/Model of Sensor UST-6B 3. Monitoring type (Sump Sensor, UST-6B Pressure, Vacuum, or Hydrostatic) 4. Sensor Third-Party Certified (Y/N) 5. Sensor Op Check Date (annually) UST Sensor Op Check Result (P/F) UST UDC Visual Inspect Date (annually) UST UDC Visual Inspection Result (P/F) UST Tightness Test Date (if monitored by Sump sensor) (required every 3 years) UST-6F/23B 10. Tightness Test Result (P/F) UST-6F/23B Dsp Dsp Dsp Dsp Dsp Dsp 1. Manufacturer of Sensor UST-6B 2. Name/Model of Sensor UST-6B 3. Monitoring type (Sump Sensor, UST-6B Pressure, Vacuum, or Hydrostatic) 4. Sensor Third-Party Certified (Y/N) 5. Sensor Op Check Date (annually) UST Sensor Op Check Result (P/F) UST UDC Visual Inspect Date (annually) UST UDC Visual Inspection Result (P/F) UST Tightness Test Date (if monitored by Sump sensor) (required every 3 years) UST-6F/23B 10. Tightness Test Result (P/F) UST-6F/23B VI. Interstitial Monitoring Results T= SB= Spill Bucket S= Sensor Status (P =Pass, F =Fail, N= None) A=Alarm History (Y=Yes, N=No) T SB T SB T SB T SB T SB T SB S A S A S A S A S A S A S A S A S A S A S A S A January February March April May June July August September October November December Page 9 9/30/09

10 Leak Detection Interstitial Monitoring (after 11/1/07) VI. Interstitial Monitoring Results (Piping) S= Sensor Status (Typically will be the STP sump) A=Alarm History (P =Pass, F =Fail, N= None) (Y=Yes, N=No) Pipe Pipe Pipe Pipe Pipe Pipe Pipe Pipe Pipe Pipe Pipe Pipe S A S A S A S A S A S A S A S A S A S A S A S A Jan Jul Feb Mar Apr May Jun Sensor < 2 off bottom? (Y, N) Aug Sept Oct Nov Dec Sensor < 2 off bottom? (Y, N) VI. Interstitial Monitoring Results (UDC) S= Sensor Status (P =Pass, F =Fail, N= None) A=Alarm History (Y=Yes, N=No) Disp Disp Disp Disp Disp Disp Disp Disp Disp Disp Disp Disp S A S A S A S A S A S A S A S A S A S A S A S A Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Sensor < 2 off bottom? (Y, N) Page 10 9/30/09

11 Leak Detection Statistical Inventory Reconciliation I. Statistical Inventory Reconciliation Information Manufacturer and Name/Model of SIR System: Is SIR System Third-Party Certified? Yes No II. Statistical Inventory Reconciliation Detail YES NO N/A 1. Were all valid fail tests reported to the division within 24 hours? 2. Were all valid fail tests investigated within 7 days? III. Statistical Inventory Reconciliation Manual YES NO 1. Do books appear used and the evidence of daily entries is apparent? 2. Is equipment capable of measuring product levels to the nearest 1/8-inch? 3. Do records indicate that product has been measured to the nearest 1/8 of an inch? 4. Are appropriate calibration charts and interpolation being used (when necessary) for calculating volume? 5. Do records include monthly water measurements? IV. Statistical Inventory Reconciliation Electronic Manufacturer and Name/Model of System / Console: Is the equipment capable of measuring product levels to the nearest 1/8? V. Statistical Inventory Reconciliation Test Results SIR Test Results: P = PASS F = FAIL INC = Inconclusive N = None YES NO January February March April May June July August September October November December Is leak detection being conducted in accordance with third party performance claim? Yes No Page 11 9/30/09

12 Leak Detection Inventory Control and Tightness Testing I. Inventory Control and Tightness Test Information YES NO 1. Is inventory control a valid method of leak detection for these tanks? * * Inventory control in combination with Tightness Testing is a temporary method of leak detection. It can only be used for 10 years after the tank is installed or cathodically protected whichever is later. II. Inventory Control Data YES NO 1. Can owner/operator explain inventory control method (including how data is used and recorded)? 2. Do books appear used and the evidence of daily entries is apparent? 3. Do records indicate that product has been measured to the nearest 1/8 of an inch? 4. Are appropriate calibration charts and interpolation being used (when necessary) for calculating volume? 5. Do records include daily over/short calculations with accumulated MTD over/short? 6. Is monthly threshold of 1% of monthly throughput plus 130 gallons being recorded? 7. Records indicate that the monthly over/short is compared with the threshold value. 8. Are all monthly over/shorts below the threshold values? (If "no", record the failed value(s) in the comments section and what response was taken.) 9. Do records include monthly water measurements? 10. Are deliveries made through a drop tube? 11. Is the gauge stick marked legibly and the product level can be determined to the nearest 1/8"? III. Inventory Control Results JAN JUL (P =Pass, F =Fail, INC =Inconclusive, N = None) FEB MAR APR MAY JUN IV. Tightness Test Information Manufacturer and Name/Model of TTT Method: AUG SEP OCT NOV DEC Is TTT Method Third-Party Certified? Yes No TTT Tester Name: TTT Testing Company: City: State: Phone Number: V. Tightness Test 1. Date of last TTT: 2. Result of last TTT: (Pass, Fail, Inconclusive) 3 Are all data sheets for TTTs available? (Y/N) 4. Was required portion of the tank tested? (Y/N) 5. Was the TTT method used valid for this system? (Y/N) 6. Was the tank tested prior to the most recent deadline? (Test required every 5 years) (Y/N) 7. Any prior tests with failed results: (Y/N) Page 12 9/30/09

13 Leak Detection Manual Gauging and Tightness Testing I. Manual Gauging and Tightness Test Information YES NO 1. Is manual tank gauging a valid method of leak detection for these tanks (see note below)? Note: Manual Gauging in combination with Tightness Testing (tanks 551 to 2k) is a temporary method of leak detection. It can only be used for 10 years after the tank is installed or cathodically protected, whichever is later. 2. Are tank tightness tests required in addition to manual tank gauging (see chart below)? 3. Do records show that liquid level measurements are taken at the beginning and ending of the appropriate time period during which no liquid is added to or removed from the tank? 4. Are level measurements based on an average of two consecutive stick readings at both the beginning and end of the time period? 5. Are monthly averages less than the monthly standard listed in the table below? 6. Can the gauge stick reach the tank bottom, is marked legibly and can measure product level to the nearest 1/8? 7. Monitoring records are available for the last 12 months? Method Number Nominal Capacity TTT Required? Weekly Standards ly Standards Minimum Test Duration 1 up to 550 gallons No 10 gallons 5 gallons 36 hours ,000 gallons Yes 13 gallons 7 gallons 36 hours 3 1,001-2,000 gallons Yes 26 gallons 13 gallons 36 hours II. Manual Gauging Results JAN (P =Pass, F =Fail, INC =Inconclusive, N = None) JUL FEB MAR APR MAY JUN III. Tightness Test Information Manufacturer and Name/Model of TTT Method: AUG SEP OCT NOV DEC Is TTT Method Third-Party Certified? Yes No TTT Tester Name: TTT Testing Company: City: State: Phone Number: IV. Tightness Test 1. Date of last TTT: 2. Result of last TTT: (Pass, Fail, Inconclusive) 3 Are all data sheets for TTTs available? (Y/N) 4. Was required portion of the tank tested? (Y/N) 5. Was the tank tested prior to the most recent deadline? (Test required every 5 years) (Y/N) 6. Any prior tests with failed results: (Y/N) Page 13 9/30/09

14 Leak Detection Vapor Monitoring I. Vapor Monitoring Information Manufacturer and Name/Model of Vapor Monitoring Sensor Console: Manufacturer and Name/Model of Vapor Monitoring Probe: Date Installed: Is Vapor Monitoring Sensor Console Third-Party Certified? Is Vapor Monitoring Probe Third-Party Certified? Number of Monitoring Wells: Yes Yes No No Name of Licensed Geologist / Professional Engineer: Certification No.: II. Vapor Monitoring Wells Detail Well Well Well Well Well Well 1. Minimum distance of wells from tank(s): 2. Minimum distance of well from piping: 3. Depth to water table 4 Well is clearly marked as Monitoring Well (Y/N) 5. Well has watertight cover (Y/N) 6. Well is locked (Y/N) 7. Well is free of debris (Y/N) III. Vapor Monitoring Questions YES NO 1. Has a UST-4 and UST-5 been submitted? 2. Is documentation available showing that the excavation zone was assessed prior to installation of the VM system? 3. Was porous material used as backfill as indicated by pre-installation site assessment? 4. Are wells within the excavation zone as indicated by pre-installation site assessment? 5. Are wells free of water and/or other interferences to vapor detection? 6. Is the level of background contamination known? (see comments) IV. Vapor Monitoring - Automatic YES NO 1. Is power box available and functioning? 2. Is equipment used to take readings accessible and functioning? 3. Has vapor-monitoring equipment been calibrated as required by manufacturer? 4. Are 14-day leak detection readings available for the last 12 months? V. Vapor Monitoring - Manual YES NO 1. Is equipment used to take readings accessible and functioning? 2. Has vapor-monitoring equipment been calibrated as required by manufacturer? 3. Are 14-day leak detection readings available for the last 12 months? VI. Vapor Monitoring 14-Day Monitoring Results JAN JUL (P =Pass, F =Fail, INC =Inconclusive, N = None) FEB MAR APR MAY JUN AUG SEP OCT NOV DEC Page 14 9/30/09

15 Leak Detection Groundwater Monitoring I. Groundwater Monitoring Information Manufacturer and Name/Model of Groundwater Monitoring Console: Manufacturer and Name/Model of Groundwater Monitoring Probe: Date Installed: Is Groundwater Monitoring Console Third-Party Certified? Is Groundwater Monitoring Probe Third- Party Certified? Number of Monitoring Wells: Yes Yes No No Name of Licensed Geologist / Professional Engineer: Certification No.: II. Groundwater Monitoring Wells Detail Well Well Well Well Well Well 1. Minimum distance of wells from tank(s): 2. Minimum distance of well from piping: 3. Depth to water table 4 Well is clearly marked as Monitoring Well (Y/N) 5. Well has watertight cover (Y/N) 6. Well is locked (Y/N) 7. Well is free of debris (Y/N) III. Groundwater Monitoring Questions YES NO 1. Has a UST-4 and UST-5 been submitted? 2. Is documentation available showing that the excavation zone was assessed prior to installation of the wells? 3. Is the hydraulic conductivity of soil between the UST system and monitoring wells greater than 0.01 cm/sec? 4. Is the depth to the water table greater than 20 feet from ground surface? 5. Are wells used to monitor piping, and placed at less than 50-foot intervals? 6. Are wells screened (slotted) from 2 ft. to 20 ft. below land surface or to 2 ft. below seasonal low water table? 7. Are wells surrounded with sand/gravel to screen top, as well as, plugged, and grouted to finished grade? IV. Groundwater Monitoring Automatic YES NO 1. Is monitoring console present and functioning? 2. Is equipment used to take readings accessible and functioning? 3. Has groundwater-monitoring equipment been calibrated as required by manufacturer? 4. Are 14-day leak detection readings available for the last 12 months? V. Groundwater Monitoring Manual YES NO 1. Is equipment used to take readings accessible and functioning? 2. Has groundwater-monitoring equipment been calibrated as required by manufacturer? 3. Are 14-day leak detection readings available for the last 12 months? VI. Groundwater Monitoring 14-Day Results JAN JUL (P =Pass, F =Fail, INC =Inconclusive, N = None) FEB MAR APR MAY JUN AUG SEP OCT NOV DEC Page 15 9/30/09

16 Siting and Secondary Containment for Underground Storage Systems Near Wells and Surface Waters I. Water Supply / Protected Waters UST Siting Issues YES NO Distance(s) 1. Is municipal water available? 2. Are there any wells serving a public water system within 500 feet of the UST system? 3. Are there any wells serving a public water system within 100 feet of the UST system? 4. Are there any other wells supplying water for human consumption within 100 feet of the UST system? 5. Are there any other wells supplying water for human consumption within 50 feet of the UST system? 6. Are there any protected surface waters* within 500 feet of the UST system? *classified as High Quality Water (HQW), Outstanding Resource Water (ORW), Water Supply I (WS-I), Water Supply II (WS-II) or Shell Fishing (SA) 7. Was the UST system installed on or before January 1, 1991? (If N skip to question 10) (Y, N) 8 Did the UST system meet the new tank system performance standards (corrosion protection, spill prevention, and overfill prevention) by January 1, 1991? The questions below pertain to sites that have tanks and/or piping between 100 & 500 feet of a public well, within 500 feet of protected surface waters, or between 50 & 100 feet of any other well used for human consumption. 9. (For tanks installed on or before January 1, 1991) Does the tank have secondary containment (required after 1/1/2008)? 10. (For tanks installed after January 1, 1991) Does the tank have secondary containment (required after 1/1/2016)? 11. Does all metal piping and ancillary equipment have secondary containment (required as of 1/1/2005)? 12. Does all fiberglass or non-metal piping and ancillary equipment have secondary containment (required after 1/1/2008)? II. Enhanced Leak Detection Records - Well Sampling YES NO N/A Have annual VOC and SVOC and metal (where applicable) sampling results of any wells been submitted to the regional office? (Only required if not upgraded with secondary containment) III. Water Supply Wells (UST systems or components installed after 11/1/2007) 1. Was the UST system and/or piping installed on or after November 1, 2007? (Y, N) 2. Is any part of the UST or piping system located within 100 ft of a public well or 50 ft of any other human consumption well? (Y, N) Page 16 9/30/09

17 Deliveries to Unpermitted s I. Evidence of Delivery Please list date(s) of delivery, how delivery was verified, etc. Date / Time of Delivery Verification Method (Verbal, Invoice*, etc.) Amount Delivered (gal) Product Type** Transporter / Carrier *Note: If invoices or delivery tickets are available please record invoice / delivery ticket numbers **Product Types: P = Premium, M = Mid-grade, R = Regular, EB = Ethanol Blend, D = Diesel, B = Biodiesel, BB = Biodiesel Blend, K = Kerosene, WO = Waste Oil, NO = New Oil, RG = Racing Gas II. Fuel Transporter(s) Information Transporter / Carrier Company Name: Phone Number: A Street Address: City: State: Zip Code: Transporter / Carrier Company Name: Phone Number: B Street Address: City: State: Zip Code: Page 17 9/30/09